Provider Demographics
NPI:1386096790
Name:BRODERICK, SHANNON (LMSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:FLEETWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:529 SE 2ND ST STE D
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2654
Mailing Address - Country:US
Mailing Address - Phone:816-581-3737
Mailing Address - Fax:816-581-3738
Practice Address - Street 1:529 SE 2ND ST STE D
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-2654
Practice Address - Country:US
Practice Address - Phone:816-581-3737
Practice Address - Fax:816-581-3738
Is Sole Proprietor?:No
Enumeration Date:2016-07-09
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10002104100000X
MO2016027520104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker